A Root Cause Analysis to Identify Delays in the Organ Donation Process
Phil Walton, Bethan Moss · Transplantation · 2012
In 2007, the Organ Donation Taskforce submitted 14 recommendations to improve Organ Donation rates throughout the U.K. Following their national acceptance, there have been significant changes to the infrastructure within the Organ Donation service in order to meet the potential for increased donors. Despite this, there remains much conjecture surrounding the length of time it takes to facilitate an organ donor (either donation after brain death (DBD) or donation after circulatory death (DCD)). It is not uncommon for the donation process to extend past 16 or even 20 hours. This places significant pressure upon on the host ICU in terms of bed capacity, staffing and resources. During this time, the donor families are present on the unit and faced with increasing delays to what has already been a tragic and emotional experience for them. In addition to this, the longer the donation process goes on the higher the chance for complications to occur with the donor and thus jeopardising the success of any potential organ transplant. The authors recognise the importance of analysing performance and improving service delivery. Through a system of process mapping, fishbone analysis and root cause analysis the timelines of 53 donors in the South Wales region were studied in order to gain a greater understanding of the total time it takes from referral to retrieval, to highlight delays in the process and see how they may be reduced. The project has revealed common themes in the delays experienced across the region. These range from the time of referral of a DBD to actually completing the BSDT, through to the length of time taken by the transplant team to mobilise and arrive once notified of a potential donor. This project hopes to highlight the areas of greatest delay and through analysis, reduce those delays for the benefit of the ICU, the donor family and eventually the transplant recipient.